A mathematician’s view on integration in health and social care

Though the answer may be integration, we don’t always know what the question is.

Similarly, though we often say “integration”, it’s not always clear what type of integration we mean. There are at least four interpretations of what we meant when we talk about “integration”:

  • Integration across any of primary, secondary and tertiary healthcare
  • Integration across health and social care (and education and housing and etc.) boundaries
  • Integration of resources and processes
  • Integration at the level of the individual.

As a mathematician by training, integration has another particular meaning to me. I thought it would be useful to reflect on what integration means from a mathematician’s perspective and so what we might learn from this in the context of health and social care.IntegrationMathematically, integration is the reverse process of differentiation. Differentiation is all about rates of change across different variables in a system. Differentiation is a way of thinking about the world as a result of combining infinitesimally small changes at particular points in time or space.

Integration, on the other hand, gives you a bigger sense of the whole. It tells you not just about rates of change but the overall picture you have: the sum total of what exists in time or space.

Differentiation is easier. It’s exciting (think Mick Jagger swaggering around a stage) and has no room for anything but the most important stuff. If there are any ‘spare’ numbers floating around then the process of differentiation gets rids of them – they disappear.

Integration, as any mathematician will tell you, is far harder. It’s a slower, altogether more considered process that requires more sophistication (think Bjork). There are some tricks you can use to make it slightly easier – such as integration by parts – but the challenge of integration remains.

And because integration is the reverse of differentiation it adds in an unknown factor: the arbitrary constant (from which this blog takes its name). Where differentiation has no space or time for the arbitrary constant, integration very deliberately includes it and recognises it. This unknown factor – an unidentified ingredient – is a vital component of integration.

(Interestingly, the only time the added, unknown ingredient of the arbitrary constant doesn’t play a part in integration is if you explicitly define the boundaries within which integration happens. By specifying these limits so exactly the arbitrary constant is cancelled out.)

If we were therefore to try and summarise what we know about integration from a mathematical point of view we’d say something like this:

  • Integration is harder than differentiation – though there are limited tricks to make it easier
  • It gives a bigger picture across a wider area than a specific view of just one point in time or space
  • It has a secret ingredient – the arbitrary constant – which his fundamental to capturing this bigger picture
  • This secret ingredient disappears only if you define exactly the boundaries of what integration is trying to achieve
  • Integration is a subtle, complex process that takes time and understanding to do.

Thus, though you wouldn’t immediately think it, the mathematical conception of integration tells us everything we need to know about successful integration in public services, especially across health and social care and beyond.

Breadline or Left Behind: social work schemes for graduates from the university of life

Frontline and Think Ahead are new routes into children’s and mental health social work respectively for graduates with a 2:1 degree or better. The principle behind them – derived from Teach First – is to attract the “brightest and best” into a job / career they may not otherwise have considered.

My feelings about these social work training programmes have developed over time. Initially I wasn’t keen, but now I feel that anything which promotes social work as a good profession should be, broadly, welcomed.

How my feelings have developed have probably reflected the way the programmes themselves have been refined since their inception. Where before there was arguably an elitist, Oxbridge focus on who the programme’s participants might be, now it feels they’re much more interested in good graduates from a broader set of universities.

I wonder, though, if by focusing only on people graduating from university with 2:1s or above we’re missing an opportunity?

What if, as well as this, we had well-resourced and targeted recruitment campaigns focused on bringing people into social work who are likely to graduate cum laude from the University of Life?

These would be people who never made it to university; a high proportion of them probably wouldn’t have A-Levels. They will have faced adversity at many points in their lives and been used to navigating a whole host of difficult environments. But, despite the many challenges they will have encountered, their character, resilience and way of thinking has meant they have flourished.

If people like this became social workers, imagine the experience and perspectives they could bring to social work! Imagine the difference they could make to people whose lives they would truly understand!

We could call such programmes Breadline or Left Behind – anything that reflected the exact opposite of what Frontline and Think Ahead represents. Without denigrating these existing schemes, though, I think we’d find ourselves with another group of people whose contribution to social work could be significant.

Now, if only we could a think tank to take up the idea…

It’s person-centred, Jim – but not as we know it

We all have our favourite “I can’t believe that actually happened” stories in social care.

Mine relates to care and support planning: whilst observing a panel process (error number 1), a Head of Social Care instructed a social worker (error number 2) to change a support plan so that all sentences were “I” statements (error number 3) from the point of view of the patient [sic] (error number 4), without going back to the person themselves (error number 5).

It would be funny if it weren’t so normal.

But we hear variations of this all the time, summarised in the line:

Of course what I do is person-centred care – it always has been

If we are honest, relatively little of what currently happens in the care and support system is person-centred (though we’re definitely moving in the right direction).

This being the case, we should ask ourselves: if it isn’t person-centred, then what is it? I think there are at least four alternatives:

  1. Money-centred care: where what people get is what commissioners can either afford, currently buy, or have always bought
  2. Provider-centred care: where the primary objective is to ensure the ongoing feasibility of an organisation rather than the people it serves
  3. Process-driven care: where filling out the paperwork or keeping the IT system happy is the main driver
  4. Professionally-driven care: where the professional knows best and tends to think of the person in front of them as another one of their caseload or a walking set of conditions

Thinking of it in this way shows why the drive to person-centred care has been so difficult: it requires significant change on a number of major fronts – the flows of money, the role of providers, the supremacy and comfort of process, and the culture of professionals.

It’s why I’m personally so excited about person-centred care and what it means for the future. It isn’t just an optional variation of what we’ve always done; it flips public services as we know them on their head. To make this happen, though, we need to be clearer on the alternatives that being person-centred is replacing.

What politics isn’t

In recent posts we’ve noted what politics currently isn’t: neither civil nor balanced.

Chris Dillow also notes here what politics isn’t, through the eyes of people who are interested in what passes for politics:

Most of those who claim to take an interest in it are not really interested in how to govern the public sphere: if they were there’d much more interest in the social sciences. Instead, they’re mere spectators in a wrestling match who are booing baddies and cheering goodies.

I cheered – well, sighed – reading this.

This begs the question: what is politics?

We’ll need to go back to Plato, Aristotle, Hobbes and Locke to get started on this. At least, though, we’re asking the right question.

 

Obama’s civility in a polarised world

We wrote last week about political polarisation, through which we include two different-but-related things: (1) exaggerated debate about public services being the norm; and (2) the role of interest groups in polarising politics.

Then up popped a video comparing Barack Obama and Donald Trump’s ways of dealing with hecklers:

This echoed David Brooks’s piece reflecting on the civility of Obama’s presidency, and the fact we’ll miss it when it’s gone:

Obama radiates an ethos of integrity, humanity, good manners and elegance that I’m beginning to miss, and that I suspect we will all miss a bit, regardless of who replaces him.

What I note about Obama is that he always plays the ball and not the player. He engages in the debate and doesn’t resort to name-calling, ad hominem  attacks or the tone someone employs.

As you would hope, he engages at the upper scales of the Hierarchy of Disagreement:

DH0: Name-calling

DH1: Ad Hominem

DH2: Responding to tone

DH3: Contradiction

DH4 Counterargument

DH5: Refutation

DH6: Refuting the central point

Our polarised political debate means Obama’s civility stands out. Perhaps we can restore civility and try to engage in what people are saying and why, rather than who they are and how they say it?

Twitter: It’s not you, it’s me

TwitterDying
Image via A Gentleman’s Journal

There I was, about to write another post on why I’m not as enamoured with Twitter as I once was (I have previous on this). The latest addition would have been prompted by this post on why Twitter still isn’t a social network, and particularly this bit:

[U]nless you’re a power user, someone sharing a unique story or a chance witness to something big, Twitter is essentially a broadcast you’re viewing[.]

But then Paul Clarke wrote a characteristically insightful and honest piece about Twitter. He notes:

[I]f you wanted to keep Twitter fresh for you, you needed to work at it.

And what did we do?

[W]e didn’t.

Dagnammit, he’s right.

For the last two years, it’s me who hasn’t put in the effort I used to with Twitter. The disappointment I have when my timeline isn’t what I want it to be is reminiscent of how I feel when I only get bills through my letterbox or promotional emails in my inbox. But there’s a reason that happens, too: I don’t send letters and only get personal emails if I’ve sent one myself.

So, you see, Twitter – it isn’t you, it’s me.

The issue I now face is that the only time someone says this is when they’re about to break up.

Thymos: the desire for recognition

Plato Chariot

The division of the soul between desire and reason was familiar to me. What wasn’t familiar is the tripartite division of the soul, between desire, reason and what is called thymos: the desire for recognition.

The implications of thymos are considerable. In fact, Hegel argued it is the desire and so struggle for recognition which is the driving force of history.

We can see this in at least three ways.

The first is to understand thymos as our sense of justice. By believing we have a certain worth then we create the possibility for a sense of injustice if that worth isn’t recognised by others. In situations of injustice we can sometimes become angry or indignant – the latter’s etymology explicitly linking our reaction to its impact on our dignity.

The second is to see that, in a world of comfort and where most material needs are met, it is the thymotic part of the soul that is capable of driving action. If we were truly satisfied – the drives of our desires and our reason are met – then we would have no requirement to struggle. But when we feel our own worth or that of others not being recognised we seek out further struggle.

The final one is to recognise that the political process, our democracy, isn’t just about the process of using evidence, making decisions and balancing the competing interests of groups for the greater good. Democracy is also a platform through which people seek recognition for themselves and their views – it is driven by thymos.

Our conception of thymos isn’t singular. One person’s desire for recognition could be the desire to recognised as superior to other people (known as megalothymia; think Donald Trump). But the force of isothymia – the desire to be recognised as equal to other people (think of every rights-based movement) – is one that appeals.

Let us recognise, then, that people seek not just to satisfy their desires or act with reason to maximise benefits to them; they also act through thymos: the desire to be recognised.